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ABSITE Review > ABSITE Review - Biliary > Flashcards

ABSITE Review - Biliary Flashcards

1
Q

What are the borders of the triangle of Calot?

A

Cystic duct (lateral), CBD (medial), liver (superior)

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2
Q

What is the blood supply of the CBD?

A

Right hepatic (lateral) and retroduodenal branches of the GDA (medial) supply to the hepatic and CBD (9- and 3-o’clock positions when performing ERCP)

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3
Q

Which layer wall is not present in the gallbladder?

A

No submucosa

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4
Q

What are the normal sizes of the CBD, GB wall and pancreatic duct?

A

CBD < 8mm (< 4mm

Pancreatic duct < 4mm

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5
Q

Where is the highest concentration of CCK and secretin?

A

Duodenum

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6
Q

What is the biliary duct that can leak after a cholecystectomy?

A

Duct of Luschka

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7
Q

What increases bile excretion?

A

CCK, secretin, vagal input

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8
Q

What decreases bile excretion?

A

VIP, somatostatin, sympathetic stimulation

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9
Q

What is the function of the gallbladder?

A

Forms concentrated bile by active resorption of Na and water

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10
Q

Where occurs the active resorption of conjugated bile acids?

A

Terminal ileum (50%)

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11
Q

Where occurs the passive resorption of unconjugated bile acids?

A

Small intestine (45%) and colon (5%)

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12
Q

What give the stool the brown color?

A

Stercobilin - breakdown product of conjugated bilirubin in gut

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13
Q

What give the urine the yellow color?

A

Urobilin - breakdown product of conjugated bilirubin in gut; some gets reabsorbed and released in urine

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14
Q

What is the rate-limiting step enzyme in cholesterol synthesis?

A

HMG CoA reductase

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15
Q

What is the cause of stones in obese vs thin people?

A

Obese - overactive HMG-CoA reductase

Thin - underactive 7-alpha-hydroxylase

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16
Q

What is the MC type of gallstone in USA? What is the cause?

A 
Nonpigmented stones (75%)
Increase cholesterol insolubilization - caused by stasis, Ca nucleation by mucin glycoproteins, and increase water reabsorption from gallbladder
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17
Q

What is the MC type of gallstone worldwide?

A

Pigmented stones

Caused by solubilization of unconjugated bilirubin with precipitation of Ca bilirubinate and insoluble salts

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18
Q

What is the usual cause of black stones?

A

Hemolytic disorders or cirrhosis, chronic TPN or pts with ilea resection

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19
Q

What are important factors for the development of black stones?

A

Increase bilirubin load, decrease hepatic function and bile stasis

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20
Q

What are the stones primarily formed in the CBD? What is the MCC?

A

Brown stones

MCC - Infection causing deconjugation of bilirubin- E. coli

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21
Q

What is Murphy’s sign?

A

Patient resists deep inspiration with deep palpation to the RUQ secondary to pain

22
Q

What are the 3 MC organisms in cholecystitis?

A

E.coli, Klebsiella, Enterococcus

23
Q

What are the risk factors for stones?

A

age > 40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)

24
Q

What are the US findings suggestive of acute cholecystitis?

A

Gallstones, GB thickening (>4mm), pericholecystic fluid

25
Q

What is a HIDA scan? What is the interpretation of the results?

A

Technetium taken up by liver and excreted in the biliary tract.
If gallbladder cannot be seen, it is secondary to cystic duct obstruction by stone –> cholecytitis
If < 40% of GB volume excreted after CCK over 1 hour –> biliary dyskenesia

26
Q

What is emphysematous GB disease? What is the treatment?

A

Gas in GB wall, usually secondary to C. perfringens, high in diabetics
Tx - Emergent cholecystectomy

27
Q

What is the MCC of gallstone ileus? What is the treatment?

A

Fistula between gallbladder and second portion of duodenum that releases stone, causing small bowel obstruction; elderly
Tx - Remove stone with enterotomy proximal to obstruction; perform cholecystectomy and fistula resection if pt can tolerate it

28
Q

What is the definitive managment of a CBD intraoperative injury based on size?

A

If <50% the circumference of the CBD, can probably perform primary repair; in all other cases, will likely need hepaticojejunostomy or choledochojejunostomy

29
Q

What is the MCC of late postoperative biliary strictures?

A

Ischemia

30
Q

What is the treatment for early (7days) CBD injuries?

A

Early - Hepaticojejunostomy

Late - Hepaticojejunostomy in 6-8 weeks

31
Q

What is hemobilia and what are some of the symptoms?

A

Fistula between bile duct and hepatic arterial system

Sx - UGI bleed, jaundice, RUQ pain

32
Q

What is the MC malignancy of the biliary tract? Where the the MC site for metastasis?

A

GB adenocarcinoma

Noncontiguos liver metastases

33
Q

What is the risk of GB cancer in a patient with porcelain gallbladder?

A

10-20%

34
Q

What are the different stages of gallbladder cancer and respective treatment?

A

Stage I - limited to mucosa - laparoscopic vs open cholecystectomy
Stage II - into the muscle - Wide resection at liver bed at segments IV and V (2-3cm margins), regional lymphadenectomy
90% present in Stage IV
Laparoscopic approach contraindicated

35
Q

What are the risk factors for bile duct cancer?

A

C. sinensis infectio, typhoid, UC, choledochal cysts, sclerosing cholangitis, congenital hepatic fibrosis, chronic bile duct infection

36
Q

Which is the MC type for bile duct cancer and treatment?

A

Klastkin tumor - Upper 1/3 –> worst prognosis

Can try lobectomy and stenting of contralateral bile duct if localizedto either lobe

37
Q

What are the other types for bile duct cancer and treatment?

A

Middle 1/3 - hepaticojejunostomy

Lower 1/3 - Whipple

38
Q

What is the MC choledochal cyst?

A

Type I - fusiform or saccular dilatation of extrahepatic ducts (very dilated)

39
Q

What is the cause of choledochal cysts?

A

Abnormal reflux of pancreatic enzymes during development secondary to bad angle of insertion

40
Q

What is the treatment for a choledochal cyst?

A

Cyst excision with hepaticojejunostomy and cholecystectomy

41
Q

What are other types of choledochal cysts?

A

Type IV - partially intrahepatic

Type V - Caroli’s disease - totally intrahepatic –> will need liver resection

42
Q

What happens in patients with UC and primary sclerosing cholangitis afte a colon resection?

A

Primary sclerosing cholangitis does not get better

43
Q

What is the long term treatment of primary sclerosing cholangitis? Why?

A

Liver transplant
PSC leads to portal HTN and hepatic failure (scarring and patching with progressive fibrosis of intrahepatic and extrahepatic ducts

44
Q

What antibodies are present in primary biliary cirrhosis?

A

Antimitochondrial antibodies

45
Q

What is the Charcot’s triad?

A

RUQ pain, fever, jaundice

46
Q

What is the Reynold’s pentad?

A

Charcot’s triad + AMS + shock

47
Q

What is adenomyomatosis?

A

Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus - Not premalignant.

48
Q

What is a granunar cell myoblastoma?

A

Benign neuroectoderm tumor of gallbladder

49
Q

What size of gallbladder polyp is worrisome for malignancy?

A

> 1cm

50
Q

What is Mirizzi syndrome?

A

Compression of the common hepatic duct by a stone in the infundibulum of the gallbladder or inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causing stricture and heaptic duct obstruction

51
Q

What are indications for asymptomatic cholecystectomy?

A

Patients undergoing liver transplant or gastric bypass procedure

ABSITE Review (32 decks)

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